Home Insurance Claim Form Notes Please complete in BLOCK CAPITALS. Policy number Claim number This form should be filled in by the person named as the Policyholder on the policy schedule. Please complete Sections A, B, C and I for all Claims then complete the section appropriate to your Claim type: Burglary Claims D, G, H. Claims under the All Risks section of your policy E, G, H. Broken glass Claims F, G, H. A Policyholder s details Title (Mr, Mrs, Miss etc) Surname Forenames Occupation Address Town County Telephone number Telephone number Telephone number (work) (home) (mobile) E-mail address Are you registered for VAT? Yes No If so, please provide your VAT number
Notes Loss details include those lost by you, or lost as a result of burglary/theft. B Loss or damage details Please describe the lost/damaged property Where was the property when the loss/damage happened? Date Time : Are you the sole owner of the property claimed for? If not, please provide details Yes No How did the loss or damage happen? If an individual employed by you in your home was responsible for the loss/damage, please give details Does any other insurance policy cover the property you are claiming for? If Yes, please provide details: Name of insurer Yes No Policy number Insurer s address Previously, have you ever suffered loss or damage that would have been covered by this policy within the last 5 years, or claimed against any insurer for any of the risks covered by this policy? If yes, please provide details: Yes No
Note: Please retain all damaged goods for inspection. C of Property Affected/Claimed for Please note that we require a written estimate for the repair/ of the property that you are claiming for. This should be provided by a retailer/tradesperson. Serial numbers should be included if claiming for electrical items is the same as the amount stated on the written estimate you have obtained. Total price paid: Total estimated cost of : Continue on a separate sheet if necessary
D Burglary Details Fill in this part if you are claiming for loss and/or damage after a burglary. How were the premises entered? Who discovered the loss? Were the premises being used or lived in at the time of the loss? If not, when were they last used or lived in? Did you report the burglary to the Garda Síochána? Yes No If Yes, please provide details: Station address Name of Garda you spoke to Please make sure you have filled in section C. Note: All Risks are items you specified on your policy for cover outside the home. e.g. jewellery E All Risks Fill in this part if you are claiming for an item covered under the All Risks section of your policy. For more information on All Risks please refer to the "All Risks" Section of your Policy Document. Was the item stolen lost damaged Where and when did you last see the property? If the loss was as a result of theft or burglary, did you report this to the Garda Síochána? Yes No If Yes, please provide details: Station address Name of Garda you spoke to Please make sure you have filled in section C. F Glass claim Fill in this part if you are claiming for broken glass. In the space below, please give a brief description of the location and size of the glass. Describe what happened to cause the damage to the glass.
G Reporting to the Garda Síochána Fill in this section if you are claiming for items which are stolen or lost. I am reporting the theft or loss of the property set out in this form From On The property is valued at approximately Certificate to be filled in by the Garda Síochána This is to certify that of (person's name) (person's address) reported the theft or loss of (property) to this station on In our records we have made a note of Zurich s interest in this property. Signature of Garda Síochána Date Garda station Stamp of Garda station H Claims checklist Please make sure you have attended to the following items below. This will allow us to deal with your claim as quickly as possible. Please tick as completed: 3 Signed your claim form Garda Stamp in cases where it is required, i.e. stolen or lost items Contact details so we may arrange an inspection if necessary Written estimate from a retailer or tradesperson for or repair of affected items Retained all damaged goods for inspection
I Data Protection Zurich Insurance plc ( Zurich ) will hold your details in accordance with our Data Protection and Privacy Policy together with all applicable data protection laws and principles. Information you supply may be used by us for the purposes of administering your policy (including underwriting, processing, claims handling and fraud prevention) within the Zurich Financial Services Group and our partners inside and outside the European Economic Area. We may share with our agents and service providers, members of the Zurich Financial Services Group, other insurers and their agents, and with any intermediary acting for you, and with recognised trade, governing and regulatory bodies (of which we are a member or by which we are governed) information we hold about you and your claims history. This includes the Insurance-Link database and the Irish Insurance Federation s anti-fraud claims matching database. We may also in certain circumstances use private investigators to investigate a claim. We may also need to collect sensitive personal data (for example, information relating to your physical or mental health or the commission or alleged commission of an offence) to assess the terms of insurance we issue/arrange or to administer claims which arise. Unless you have advised us otherwise, we may share information that you provide to companies within the Zurich Financial Services Group and with other companies that we establish commercial links with so we and they may contact you (by email, SMS, telephone or other appropriate means) in order to tell you about carefully selected products, services or offers that we believe will be of interest to you. Please tick here if you do not wish your information to be utilised for these purposes You have a right of access to and a right to rectify data concerning you under the Data Protection Acts 1988 and 2003. Should you wish to exercise this right, please write to the Data Protection Officer, Zurich, Zurich House, Ballsbridge Park, FREEPOST, Dublin 4. To access your data, a fee of 6.35 is chargeable under the terms of the Data Protection Acts and cheque should be made payable to Zurich. By providing us with your information and proceeding with this contract, you consent to all of your information being used, processed, disclosed, transferred and retained for the purposes of insurance administration (including underwriting, processing, claims handling and fraud prevention). Please note that a copy of our full Data Protection and Privacy Policy can be viewed on our website www. zurich.ie or requested by writing to our Data Protection Officer at Zurich, Zurich House, Ballsbridge Park, FREEPOST, Dublin 4. J Declaration I declare that, as far as I know, the information I have given is true. I authorise you, and any solicitor you appoint, to deal with all matters arising from this incident as you see fit and, if appropriate, admit liability or negligence on my behalf. I understand that Zurich may record telephone calls for security and training purposes, for fraud or crime prevention and to ensure the highest level of service. I am aware that I may appoint an Independent Loss Assessor to act on my behalf and help with the preparation of my claim, but the cost of such will be at my own expense. Signature of Policy Holder Date 132232A01 ZURG/0061-1 (04/11) ZCA Zurich Insurance plc Zurich House, Ballsbridge Park, Dublin 4, Ireland. Telephone: 01 667 0666 Fax: 01 667 0644 Website: www.zurich.ie Zurich Insurance plc is regulated by the Central Bank of Ireland.